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Pharm I: Exam 2 > RA > Flashcards

Flashcards in RA Deck (39):
1

What is Rheumatoid Arthritis (RA)? 

Chronic, systemic inflammatory disease of the joints and related structures

2

What is the pathophysiology related to RA?

  • Immune-mediated inflammatory process
  • Attacks synovium and other vital organs/tissues
  • Erosive, symmetric joint involvement (frequently hands and feet)
  • Chronic inflammation of synovial lining ( tissue exceeds borders and erodes into bone and cartilage within joint capsule pannus
  • End result: joint destruction and deformity

3

What are key clinical features of RA?

  • Morning stiffness that subsides after at least 30 minutes
  • Stiff, painful, tender and/or swollen joints ("boggy" and warm to palpate)
  • Progressively symmetrical presentation (Polyarticular)
  • Hand/Foot deformities (e.g. Swan-neck, Boutonniere, ulnar deviation, 'hammer' toe)
  • Constitutional S/Sx

4

What is the primary objective and goal of therapy for RA?

  • Objective: To improve/maintain functional status and improve QOL
  • TX Goal: To relieve pain, preserve joint function and prevent/control joint destruction and systemic complications

5

What are non-drug therapy options for RA?

  • Rest
  • PT/OT
  • Assistive devices
  • Weight reduction/management
  • Splinting/join protection

6

What are DMARDs?

(disease modifying anti-rheumatic drugs) a group of drugs that have potential to prevent joint damage

7

What is the MOST common monotherapy for RA?

Methotrexate (MTX); other may also be used

8

What are the most common Double DMARD therapy?

Any double combination of MTX, SSZ, HCQ, LEF

9

What is utilized in triple DMARD therapy

MTX + SSZ + HCQ

10

What medications are classified as  Non-biologic DMARDs? (4)

  • ​​Hydroxychloroquine (HCQ)
  • Methotrexate (MTX)
  • Sulfasalazine (SSZ)
  • Leflunomide (LEF)

11

How does Hydroxychloroquine (HCQ) function?

Antimalarial; slows progression of erosive bone lesions (may induce remission); relatively fast onset (2-6 months; D/C if no response >6 months)

12

What are therapeutic uses for Hydroxychloroquine (HCQ)?

  • Mild RA
  • Combination (Double/Triple DMARD therapy)
  • Reserved for RA unresponsive to NSAIDs

13

What should be monitored when utilizing Hydroxychloroquine (HCQ)?

Minimal

  • Ophthalmologic exam bi-annually (retinal toxicity)
  • Does not cause liver/kidney/ bone toxicities

14

What are ADRs associated with Hydroxychloroquine (HCQ)?

  • GI: N/V/D (take with food)
  • Derm: pruritus, rash, alopecia, INC skin pigmentation
  • Neuro: HA, insomnia, vertigo
  • Ocular Toxicity

15

How does Methotrexate (MTX) function?

Acts as immunosuppressive and anti-inflammatory agent (folic acid antagonist); slows appearance of new erosions

16

What are therapeutic uses for Methotrexate (MTX)

  • 1st LINE monotherapy DMARD
  • MAINSTAY moderate to severe RA (patients not responding to NSAIDs adequately)
  •  

17

What are ADRs for Methotrexate (MTX)?

  • GI: N/V/D, stomatitis (dose-related)
  • Hematologic: thrombocytopenia, leukopenia
  • Pulmonary: fibrosis, pneumonitis 
  • Hepatic: ELEVATED liver enzymes, cirrhosis

18

What is a drug interaction with Methotrexate (MTX)

  • NSAIDs (may DEC Clearance, INC ADRs)

19

What should be monitored when utilizing Methotrexate (MTX)

  • Baseline: LFTs, CBC, Total bilirubin, HBV and HCV studies, serum Creatinine, albumin 
  • Q1-2 months: CBC, AST, albumin

20

How does Sulfasalazine (SSZ) function?

PRODRUG cleaved in the colon to sulfapyridine (anti-rheumatic properties)

21

What are the therapeutic uses for Sulfasalazine (SSZ)?

  • Mild RA
  • Combination (Double/Triple)

22

What should be monitored when utilizing Sulfasalazine (SSZ)?

  • Baseline: CBC
  • Month 1: CBC Q week 
  • Continuing: CBC Q 1-2 months

23

How does Leflunomide (LEF) function?

  • Interferes with RNA/DNA synthesis in lymphocytes (reversible inhibitor of DHODH)
  • Reduces pain and inflammation associated with RA  (slows progression of structural damage)

24

What are ADRs associated with Leflunomide (LEF)?

  • N/V 
  • HA
  • Rash
  • Alopecia
  • Liver toxicity (CAUTION with Liver disease)
  • Pregnancy Category X  (Wash cholestyramine out prior to conception)

25

What medications are classified as Tumor Necrosis Factor (TNF) Antagonist? (3)

(Biologic DMARDs)

  • Etanercept
  • Infliximab
  • Adalimumab

 

 

26

How does Entanercept function?

Soluble TNF receptor that competitively binds 2 TNF molecules (renders inactive)

27

How do Infliximab and Adalimumab function?

Anti-TNF alpha monoclonal antibody (IgG) that inhibit progression of structural damage

28

What should be monitored when utilizing Anti-TNF agents?

  • Initial tuberculin skin test
  • Additive effects when in combination with Methotrexate (MTX)
    • Infliximab only: Human anti-chimeric molecule Ab development

29

What ADRs are associated with Infliximab?

Infusion-related HA/Nausea

30

What ADRs are associated with Etanercept and Adalimumab?

Injection site reactions

31

What medications are classified as Interleukin-1 receptor Antagonist? (1)

Anakinra (TX moderate to severe RA)

32

How does Anakinra function? 

  • Slows degradation of cartilage and bone resorption
  • TX options: Monotherapy or Combo w/ MTX

33

What are ADRs associated with Anakinra?

  • Similiar to Anti-TNF agents
  • Injection site reactions 
  • DO NOT USE combo with Anti-TNF (reserve for after Anti-TNF therapy is unsuccessful

34

What medications are classified as Non-TNF agents? (3)

(Biologic DMARD)

  • Abatacept
  • Rituximab
  • Tofacitinib

35

How does Abatacept function?

  • Inhibits T-lymphocyte activation (soluble fusion protein)
  • TX options: monotherapy or combo
  • VERY EXPENSIVE

36

How does Rituximab function?

  • Depletes B lymphocytes (reduces Ab formation)
  • Combo with MTX for moderate to severe cases with inadequate response to ANTI-TNF agents (FDA)

37

How does Tofacitinib function?

  • Inhibits Jaus kinase (JAK) enzymes (intracellular enzymes involved in stimulation of hematopoiesis and immune cell function)
  • BLACK BOX WARNING (infections and malignancy)
  • TX Option: monotherapy or combo W/ MTX or non-biologics (TX Moderate to severe RA)

38

Why are corticosteroids useful in RA treatment?

Could be used as a bridge to control debilitating symptoms until DMARDs take effect

39

What medications may alleviate ADRs associated with Methotrexate?

  • Folic Acid (may alleviate ADRs)
  • Leucovorin (folic acid derivative, antidote to MTX toxicity)